What are the best implant options for treating intertrochanteric fractures?

Choosing Between Intertrochanteric Fracture Implant Options

Primary Recommendation

For unstable intertrochanteric fractures, reverse obliquity patterns, and subtrochanteric fractures, use cephalomedullary nail fixation; for stable intertrochanteric fractures, a sliding hip screw is the preferred option. 1

Algorithmic Approach to Implant Selection

Step 1: Classify Fracture Stability

Stable Intertrochanteric Fractures:

• Use a sliding hip screw (dynamic hip screw) as the first-line treatment 1
• This includes simple two-part fractures with intact lateral and posteromedial cortices 1

Unstable Intertrochanteric Fractures:

• Use cephalomedullary nail fixation for comminuted patterns, loss of posteromedial support, or lateral wall compromise 1
• Mandatory indications for cephalomedullary nailing include reverse obliquity fractures and subtrochanteric extension, where strong evidence supports this approach over sliding hip screws 1

Step 2: Select Nail Length (When Using Cephalomedullary Fixation)

• Either short or long cephalomedullary nails may be used for standard unstable intertrochanteric fractures, as evidence does not clearly favor one over the other 1
• Long nails provide theoretical protection against subtrochanteric extension and subsequent femoral shaft fractures, particularly relevant in osteoporotic bone 1

Step 3: Consider Special Implant Features

Standard cephalomedullary nails (PFNA, Gamma3):

• Shorter operative times compared to dual-screw systems 2
• Well-established track record with predictable outcomes 2

Dual cephalocervical screw systems (InterTAN):

• Provide superior resistance to implant cut-out and screw migration compared to single-screw designs 2
• Linear compression mechanism may reduce neck shortening and malunion 3, 2
• Longer operative times but potentially fewer mechanical complications 2
• Consider for fractures at higher risk of rotational instability 3

Critical Technical Considerations

Reduction Quality:

• Anatomical or near-anatomical reduction is essential regardless of implant choice 4
• Even with optimal technique, some loss of reduction during healing is inevitable, averaging 4.5 mm of neck shortening and 5.4° loss of neck-shaft angle 4
• Unstable fracture patterns experience greater reduction loss than stable patterns 4

Blade/Screw Positioning:

• Optimal positioning in the femoral head is critical to minimize cut-out risk 1, 4
• Despite perfect technique, blade migration averaging 1.8 mm cut-out and 1.3 mm cut-through still occurs during healing 4

Common Pitfalls to Avoid

Using sliding hip screws for unstable patterns:

• Dynamic hip screws have significantly higher rates of excessive sliding, nonunion, and mechanical failure in unstable fractures compared to cephalomedullary nails 5
• The nonunion risk is particularly elevated with dynamic hip screws in comminuted fractures 5

Inadequate assessment of fracture stability:

• Reverse obliquity and subtrochanteric extension patterns appear deceptively simple on AP radiographs but require cephalomedullary fixation 1
• Lateral wall integrity must be carefully evaluated, as compromise mandates intramedullary fixation 1

Delayed recognition of concomitant femoral neck fractures:

• When ipsilateral femoral neck and intertrochanteric fractures coexist, choose between cephalomedullary nail or hip arthroplasty based on neck fracture displacement and patient age 5
• Dynamic hip screws have unacceptably high complication rates in this combined injury pattern 5

Postoperative Management

Weight-bearing protocol:

• Allow immediate full weight-bearing as tolerated after cephalomedullary nail fixation 1
• This applies to both stable and unstable fracture patterns treated with intramedullary devices 1

Monitoring for complications:

• All fractures treated with appropriate technique and implant selection should heal within 16 weeks 3
• Persistent pain or delayed healing warrants evaluation for reduction loss, cut-out, or infection 4